Attention: Medical Review/Authorization
1234 Insurance Blvd. South, Suite #A
La City, NW 12345-7890
Re: Client's Name
Social Security Number
"Policy" or "Account Number"
Dear (Medical Consultant, VR Counselor, Personal Care Representative, Special Education Director, etc.)
Paragraph One - Short Introduction
One or two sentences about the device and the services requested and why.
Identification of supporting documentation included as attachments (e.g., assistive technology assessment, price quotation from vendor, letters/opinions of medical necessity from specialists, brochure or other information showing device).
Paragraph Two - Information About the Client
Personalize your client and provide information needed to acquaint decision-maker with situation. Include the following as appropriate:
- Name, age, sex, diagnosis.
- Current living/housing status (where does the client live; with whom does the client live; availability or need for personal assistance).
- Current school or employment status.
- Primary care physician, hospital and clinic affiliation if appropriate.
- Diagnosis, expected clinical course and prognosis. Be as specific and inclusive as possible; describe changes in condition. Height and weight comparisons, planned or completed surgeries. X-ray findings and other relevant medical diagnostic testing as appropriate.
- Information regarding functional limitations connected to diagnosis.
- Current equipment and experiences in using that equipment.
- Cognitive status.
- As needed, describe efforts to obtain funding through other sources.
Paragraph Three - Equipment Requested
- Describe the equipment in detail. A prescription that simply says "electric wheelchair" or "augmentative communication system" will not be adequate since there are many different varieties of communication systems and power chairs. Address the need for any added components (e.g. cushions, joysticks, positioning belts, mounting devices, etc.): Discuss duration of expected usage of equipment.
- Describe the consumer's actual experience and success in using the device. Show the functional benefits of the equipment to the consumer - e.g., tell the decision maker what the equipment will allow the consumer to do. You may want to include a picture or video of the consumer using the device.
- Explain why other devices were ruled out - especially less expensive devices.
- Show the need for the device in language that tracks the funding source's criteria for e.g., "medical necessity," achieving a "free and appropriate public education" or overcoming barriers of employment. Describe why the device is not a "convenience item."
- Consider the following rationales:
- Is the device needed to prevent further injury or pain? Is it a cost-effective means of preventing secondary complications or further functional limitations?
- Is the device needed for effective communication including communication for medical purposes?
- What is the impact of the device on the client's mental health? How does the consumer's mental health impact his/her medical, educational, vocational status?
- Will the device reduce dependence/reliance upon other services funded by this agency such as nursing care or hospitalization?
- Is the device a "substitute" (in effect, a prosthetic or orthotic device) for a lost functional capability such as vision, hearing, or mobility?
- Will the device allow the client to continue to live at home and/or keep him out of a nursing home or hospital?
- Will it allow the client to meet his/her educational goals?
- If you can keep part of an existing device, talk about the cost savings.
- Mention potential for growth, modification and adjustments that will ensure long-term use of the device.
- Describe the cost of the equipment and why the particular vendor was chosen (e.g. good reputation, experience with that vendor, preferred provider with your insurer, only vendor in town).
Paragraph Four - Needed Support Services/Plans for Assessment & Follow-Up
- Describe any needed support services such as training, maintenance and repairs and how these services will be funded.
- Describe the plan and follow-up on use of device.
- Describe contributions from any other funding sources.
Paragraph Five - Summary
- Identify attachments if you have not already done so.
- **Whom to contact for additional information/questions.**
- Thank you.
- Use co-signatures of appropriate medical/vocational professionals.
- Letters from Primary Care Physician & specialists if appropriate.
- Assistive Technology Assessment.
- Pictures/videos showing consumer using device/costs.
- Information from Vendor on device/costs.
- Brochure/letter describing assistive technology device.
- Required Agency forms.